|Level of blockade||Coverage distribution|
|Lumbar plexus in the psoas muscle, shortly after it exits the spine|
- Femoral nerve: quadriceps muscle, anterior aspect of thigh, medial aspect of lower leg (saphenous nerve), anterior aspect of acetabulum and femur, portion of proximal tibia
- Lateral femoral cutaneous nerve: lateral aspect of hip and thigh
- Obturator nerve: adductor muscles, medial femur
- Ilioinguinal, iliohypogastric, genitofemoral: usually blocked as well
Figure 141-1. Distribution of Cutaneous Anesthesia and Analgesia from a Lumbar Plexus Block
Reproduced from Hadzic A. The New York School of Regional Anesthesia Textbook of Regional Anesthesia and Acute Pain Management. Figure 33-3. Available at: www.accessanesthesiology.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.
- The lumbar plexus originates from L1 to L4, with often a contribution from T12. L4 gives off a branch that merges with L5 to form the lumbosacral branch, part of the sacral plexus
- Branches of the lumbar plexus include:
- Femoral nerve
- Lateral femoral cutaneous nerve
- Obturator nerve
- Ilioinguinal, iliohypogastric, and genitofemoral nerves
- The lumbar plexus courses through the lumbar area and the pelvis in the sheath of the psoas, and then the iliopsoas muscle (Figure 141-2)
Figure 141-2. Lumbar Plexus Anatomy
Reproduced from Morgan GE Jr, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed. Available at www.accessanesthesiology.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.
- Postoperative analgesia of hip or knee surgery (associated or not to a sacral plexus block); probably no advantage over femoral nerve block for knee surgery:
- Hip arthroscopy
- Proximal femur ORIF
- Hip hemiarthroplasty/THA
- Anesthesia for lower extremity surgery, in association with a sacral plexus block
- The block of the obturator nerve is reliable, contrary to the femoral paravascular block, and the block is more proximal, with theoretically a better coverage of the hip
- When combined with a sciatic block, take into account total dose of local anesthetic
- This is an advanced block and should only be performed by experienced practitioners because of potential severe complications
- Significant coagulopathy; this is a deep block, and a psoas sheath bleeding may go unnoticed, and is not amenable to compression:
- Single-injection or continuous psoas compartment block should be treated as neuraxial blocks with regards to coagulation issues
- Significant lumbar spine deformity, as the position of the lumbar plexus might be distorted
Technique using NS (Figure 141-3):
- Patient in lateral decubitus, side to be blocked up, nondependent lower extremity slightly flexed; stand behind patient
- Draw Tuffier's line (joining the iliac crests): line A
- Draw a line over the spinous processes (feel for the ...
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